Definition

Clinically significant weight loss: ≥2% decrease of baseline weight in one month, ≥ 5% decrease in three months, or ≥10% in six months

• Loss of as little as 5% weight over a three year period is associated with increased mortality among community-dwelling older adults
• 15% of patients age >70 have protein-calorie malnutrition at admission

Differential Diagnosis

• Malnutrition does not require presence of underlying illness
• Assess for sarcopenia/muscle atrophy
• Assess for causes of inadequate dietary intake and/or appetite loss (anorexia)
  • Social: access to food, poverty, lack of transportation, isolation
  • Psychological: depression, dementia, delirium, substance abuse
  • Medical:
    • Physiologic aging: decreased taste and smell, delayed gastric emptying
    • Medications (e.g. insulin, anticholinergics causing sedation or swallowing dysfunction, alendronate causing esophagitis)
    • Mechanical: no teeth, dysphagia, paralysis, severe arthritis, hand tremor, poor mobility
    • Systemic disease: malignancy, GI disease, hyperthyroidism, end organ disease (CHF, renal failure, etc.), chronic infection, rheum disease, and many more → Inflammatory effects of disease (cachexia)

Common Micronutrient Deficiencies in Elderly

• B12 deficiency: 10-20% prevalence
• Vitamin D deficiency: associated with increased fractures and falls in elderly. Give 800-1000 units daily.
• Calcium: inadequate intake associated with increased fractures. Give 600mg BID.

Evaluation and Management of Poor Nutrition

• Address goals of care and patient and family priorities
• Address underlying factors (above)
• Assess current diet
  • Is diet appropriate (e.g. can the patient chew a regular diet with current dentition)?
  • Lift dietary restrictions if possible (e.g. in diabetic patients with nutritional concerns, consider stopping No Concentrated Sweets diet and instead adjust diabetic meds)
  • Consider calorie count, nutrition consult, speech/swallow consult
• Nutritional supplements: consider once underlying factors and diet have been addressed
  • Supplements shown to increase weight gain but no change in functional status. Greatest benefit seen in hospitalized, undernourished patients who were ≥75. No difference in mortality in people living at home
  • Standard supplements vary from ~200-425 cal/8 oz can
  • Examples: Ensure Plus, Enlive (clear liquid, fat free), Glucerna (diabetes), Nepro (CKD)
• Multivitamin: give if insufficient caloric intake
• Avoid appetite stimulants: not well studied in elderly
  • Mirtazapine: Can trial at lower dose for sleep (7.5-15mg QHS) or higher doses for appetite stimulation and depression treatment
  • Megace (megestrol acetate): Demonstrated weight gain and improved QOL in cancer and AIDS patients but limited by side effects of edema, worsening of CHF, muscle loss, adrenal insufficiency, DVT risk
  • Marinol (dronabinol): Improves appetite in AIDS patients. Not as effective as Megace in patients with cancer. CNS side effects limit use in most elderly
• Tube feeding
  • No data to show benefit in survival, pressure ulcers, aspiration events, infection, consequences of malnutrition, functional status, or patient comfort
• Assess for risk of refeeding syndrome and monitor if appropriate

Inability to Care for Self - “Failure to Thrive”

• Institute of Medicine definition is a syndrome that includes:
  • Weight loss > 5% of baseline
  • Decreased appetite
  • Poor nutrition
  • Inactivity
• May be associated with dehydration, depression, low cholesterol levels
• May indicate a mismatch between current living situation and patient needs and resources - involve SW and CM as well as PCP and family for context.
• Don’t anchor on “FTT” diagnosis: assess for acute or subacute illness, poor access to nutrition, depression, loneliness and isolation, elder abuse, and other geriatric syndromes

Caring Wisely

• Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults
• Optimize social supports, provide feeding assistance, and clarify patient goals and expectations.
• Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead offer oral assisted feeding.

AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2014 May;62(5): 950-60.

Finucane, TE, Christmas, C, Travis, K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999; 282:1365.

Milne, AC, Avenell, A, Potter, J. Meta-analysis: protein and energy supplementation in older people. Ann Intern Med 2006; 144:37.

Morley, JE, Silver, AJ. Nutritional issues in nursing home care. Ann Intern Med 1995; 123:850.

Newman, AB, Yanez, D, Harris, T, et al. Weight change in old age and its association with mortality. J Am Geriatr Soc 2001; 49:1309.

Zawada, ET Jr. Malnutrition in the elderly. Is it simply a matter of not eating enough? Postgrad Med 1996; 100:207.